There is a long felt need in the health care industry to provide an employer sponsored health insurance policy that simultaneously covers the majority of an employee's health care costs while at the same time encourages cost savings behavior by the employee.
Co-pending US patent application “Pharmacy Benefits Design”, U.S. application Ser. No. 11/119,125 filed Apr. 29, 2005, for example, describes a system and method for providing health insurance to an employee (i.e., an “insured” or a “subscriber”) wherein the health insurance comprises a pharmacy benefits plan and wherein the pharmacy benefits plan provides a monetary allowance for each prescription of drugs that the insured purchases. If the insured purchases a drug, the insured only has to pay for the cost of the drug that is in excess of the allowance up to a per script maximum. The plan is referred to herein as an RxImpact plan.
All drugs within an RxImpact plan are categorized into one of four or five Groups. The Groups are A, B, C, D and optionally E. All drugs within the same group have the same allowance per prescription.
Each group contains all drugs that have a similar effect on anticipated future medical costs that an insured would face if they did not take the drugs in a timely manner. Drugs are assigned to Group A, for example, if it is anticipated that not taking them would result in significant future medical costs for an insured within one year. Antibiotics, for example, would be categorized as Group A drugs. If an insured did not take an antibiotic when prescribed, then it is anticipated that the insured would likely require future medical treatment, such as an emergency room visit or a hospitalization.
Group B drugs might comprise those that would result in significant medical costs which are incurred in a time frame that exceeds one year. Anti-cholesterol drugs are an example of Group B drugs. If an individual fails to take his/her anti-cholesterol medication in the short term, that individual may have a heart attack requiring hospitalization some time in the future.
Group C drugs might comprise those that would not result in future medical costs if not taken, but might result in increased employee productivity. Non-sedating antihistamines are examples of Group C drugs.
Group D drugs might comprise those that would not result in either subsequent health care costs or reduced employee productivity if not taken, but might improve an insured's lifestyle. Hair restoration drugs are examples of Group D drugs.
Optional Group E drugs might comprise those that do not fall into one of the above four Groups. Anesthesia drugs are examples of Group E drugs.
Under an RxImpact pharmacy benefits plan, both generic and brand name drugs that are prescribed for the same indication would be assigned to the same Group. Lipitor (brand name) and Lovastatin (generic) are both prescribed for the treatment of high cholesterol and would therefore, be assigned to the same Group, Group B. They would also, therefore, have the same allowance.
Furthermore, drugs prescribed for different indications might also be assigned to the same Group provided they had similar impact on subsequent medical costs. Antibiotics and diabetes drugs, for example, are prescribed for very different indications. Antibiotics are prescribed to treat infections. Diabetes drugs are prescribed to control blood sugar. Yet both antibiotics and diabetes drugs would be assigned to Group A since it is anticipated that not taking either of them would result in subsequent higher medical costs, such as an emergency room visit, within a year.
Different Groups of drugs in an RxImpact plan might have different allowances per prescription. Group A drugs, for example, might get an allowance of $30 for each prescription. Group B drugs might have an allowance of $20 per prescription. Group C drugs might have an allowance of $10 per prescription. Groups D and E might not have an allowance.
Group D drugs might not have an allowance since an employer offering an RxImpact plan to their employees might not wish to provide health care coverage for drugs that are primarily prescribed to enhance a person's lifestyle but do not result in the reduction of subsequent health care costs or increased employee productivity.
Group E drugs might not have an allowance since they are not covered by the RxImpact Plan.
Often times the cost of a given prescription is less than the allowance for the prescription. It has been discovered that the concept of an RxImpact plan would be more acceptable to employees and employees might be more savvy shoppers if a means could be provided whereby the employees could accumulate monetary credits for any unused portion of a given allowance provided for a given pharmaceutical purchase. An RxImpact plan would also be more acceptable if the monetary credits could be accumulated by employees without the employees having to declare the monetary credits as taxable income. An RxImpact plan would also be more acceptable if a convenient means could be provided to inform employees of the accumulation of their monetary credits. An RxImpact plan would also be more acceptable if a convenient means could be provided for employees to redeem their monetary credits for other health care costs beyond merely pharmaceutical costs.